Employment Application Template
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1
2Lebanon Valley Mall DQ
Dairy Queen West
2600 West Cumberland St.
(717) 272- 8786
(717) 272- 8786
RETURN APPLICATION
Dairy Queen of Palmyra
SEALED IN THE
5 North Londonderry Square
PROVIDED ENVELOPE
(717) 838-5900
EMPLOYMENT APPLICATION
We are an equal opportunity employer. No question is asked for the purpose of excluding any applicant due to race, creed, color, national
origin, age, sex, veteran status, disability, or any other class of individuals protected by law.
PERSONAL
Social Security Number
Last Name
First Name
Middle Name
Current Mailing Address
Street
City
State
Zip
Permanent Address (if different from above) Street
City
State
Zip
Phone Number
Cell Phone Number (if applicable)
Date of Birth:
□
□
Are you Legally authorized to work in the United States?
Yes
No
POSITION APPLYING FOR
Hrs.Available
M
T
W
Th
F
S
Su
□
□
□
□
Are You Interested In:
Full
Part
Temporary
Seasonal
From
Have you ever worked in a fast food franchise before?
To
□
□
Yes
No
Date Available:
Salary Acceptable
TOTAL HOURS
If yes, for whom? _________________________________
Per Hour:
Available Per Week
From ____/_____/________ to ____/____/_________
Who Referred You To This Job?
Phone Number
Have you ever been convicted for a crime other than a major traffic violation?
(This information will be considered in hiring or job placement but
□
□
Yes
No If Yes, Explain:
will not automatically disqualify you for employment)
EDUCATION
Highest Grade Completed
Post Secondary
Other (Specify)
Grade Point Average
7 8
9
10
11
12
1
2
3
4
ACTIVITIES
Class Organizations, Scholastic Honors, and other school activities
(At your option, you may exclude organizations which indicate race, age,
sex, creed, color, national origin, religion, or other protected class.)
Hobbies and Recreational Interests
EMPLOYMENT RECORD
Name & Address of Present Employer
Employment Dates
From ____/_____/________ to ____/____/_________
Supervisor’s Name
Title
Phone
Position
Starting Salary
Final Salary
Reason for Leaving
May we contact this employer?
□
□
□
Yes, Immediately
Yes, at a Later Date
No, do not contact
Name & Address of Most Recent Employer
Employment Dates
(if other than present, if applicable)
From ____/_____/________ to ____/____/_________
Supervisor’s Name
Title
Phone
Position
Starting Salary
Final Salary
Reason for Leaving
May we contact this employer?
□
□
□
Yes, Immediately
Yes, at a Later Date
No, do not contact
INTERVIEW DATE AND TIME: ___/____/____
____:____ DATE HIRED: ____/____/____
OFFICE USE ONLY:
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Parent category: Business